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NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Student Name

Capella University

NURS4050 Coord Patient-Centered Care

Prof. Name


Final Care Coordination Plan

This care coordination plan is based on evaluating the preliminary care coordination plan developed in Assessment 1 for mental health issues in the Lodi Community. This plan focuses on developing patient-centered interventions considering ethical implications, health policy provisions, and Healthy People 2030 objectives using evidence-based research. Mental health is the psychological and emotional well-being of individuals that assists them in addressing stressful life situations and recognizing their abilities to contribute positively to the community (WHO, 2022). 

Patient-centered Health Interventions and Timelines for Mental Health 

Various issues under the domain of mental health must be eradicated using patient/population-centered interventions. These issues are; limited mental health literacy, inadequate community support programs, and mental health issues in school-going children and adolescents.

Mental Health Literacy/Education

A patient-centered intervention to address this concern is the implementation of educational campaigns. The purpose of these campaigns is to disregard the stigma associated with mental health conditions and promote sharing and discussions related to mental well-being. These campaigns will be conducted in the form of awareness sessions. Social media applications will be used for a wider spread of information, as they are considered effective in promoting mental health awareness (Latha et al., 2020). The timeline for this intervention is divided into two sections – 1) development of the application, which will be done within three months, and 2) awareness sessions, which will be continuously conducted once per month. Furthermore, community resources like mental health advocates, community care centers, and psychological well-being clinics will be utilized to achieve the desired objectives. 

Community Support Networks

Another important healthcare challenge is inadequate community support resources. The establishment of community support groups can address this challenge. The goal is to create at least five support groups within the year’s timeline. Effective mobilization of community stakeholders such as leaders, faith-based organizations, financial resources, healthcare organizations, and governmental support is essential for fulfilling the community-based initiative (Siddiqui et al., 2022). 

School-based Mental Health Programs

A patient-centered intervention is establishing a school-based mental health curriculum to address the rising prevalence of mental health issues in children and adolescents. This educational intervention is vital to minimize the risks of mental health issues in the concerned population, early detection of signs, which is important for early intervention, and improve mental health literacy from an early age (Richter et al., 2022). The timeline for this intervention is that the planning should begin within a month, the course should be developed in 3 months, and the execution of the curriculum should begin within six months. Initially, a pilot project should be undertaken for 3-6 months, which after evaluation and modification, should be implemented in all schools. Educators, school administrators, and healthcare professionals in the mental health domain are major community resources required for this project. 

Ethical Decisions Related to Patient-centered Health Interventions

Ethical considerations are crucial when designing patient-centered health interventions related to mental health issues due to the associated stigma. Cultural sensitivity and acceptance of diversity are two major ethical concepts that must be considered while developing educational/awareness campaigns for the community. It is imperative to develop culturally sensitive content that recognizes the unique mental health challenges faced by various racial/ethnic groups within the community. Besides, using social media applications raises ethical concerns about privacy and confidentiality (Ahmed et al., 2020).

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

In this regard, it is crucial for healthcare providers to adhere to the rules of maintaining patients’ privacy and confidentiality during the implementation of social media for information-sharing purposes. Establishing community support networks comes with the ethical principle of justice whereby every individual member should receive equitable community resources and fair treatment. A study by Creary (2021) suggests that applying justice and efficiency in terms of the allocation of resources can lead to health equity and minimize disparities. Lastly, developing a school-based mental health curriculum involves the ethical principles of autonomy and informed choices. Students/parents should be given the autonomy to decide what is best for their healthcare based on the curriculum’s evidence-based informed risks and benefits. 

Coordination and Continuum of Care Related to Mental Health – Healthcare Policies

Several policies significantly impact care coordination related to addressing mental health issues in communities. 

Mental Health Parity and Addiction Equity Act (MHPAEA)

This health policy was developed in 2008 to reduce inequalities and disparities in accessing mental health services. Further amended under the Affordable Care Act (ACA) policy, this act instructs health insurance providers to give equal coverage to mental health and substance abuse concerns as provided for other physical health conditions (CMS, n.d.). The provisions of this policy improve healthcare accessibility for patients with mental health illnesses reducing financial barriers, leading to early interventions and improved quality of life through coordination of care. 

21st Century Cures Act

The Cures Act aims to enhance health outcomes for individuals with mental health and substance abuse issues, especially in the criminal population. This act reduces racial disparities and provides equal opportunities for the concerned population so that the continuity of care is maintained and individuals receive equitable access to healthcare (Cole et al., 2018). Furthermore, this legislation also provides funding for mental health initiatives, encouraging coordination and integration of mental health services within primary care settings.

Priorities and Evidence-based Changes in Care Coordination

While engaging in discussions with patients and their families, the care coordinator must establish the priorities to ensure effective communication of the care plan. Comprehensive assessment and goal-setting is an initial priority where the care coordinator will assess patients’ physical, mental, and psychosocial needs.

Engaging the patient and their family member in dialogue allows the coordinator to gain valuable insights into the patient’s medical history, current symptoms, and personal preferences. This approach is essential for providing patient-centered care and establishing realistic and meaningful goals. The need for changes to the plan arises from evidence-based practice. These practices emphasize the importance of individualized care plans targeting specific goals to optimize health outcomes (Bolton et al., 2020). By modifying the plan based on the latest research and clinical guidelines, the care coordinator ensures that the patient’s care is aligned with the best available evidence.

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Another priority is to provide holistic care that addresses the patient’s physical, emotional, and social well-being. Care coordinators should integrate medical treatments with mental health support, dietary considerations, and lifestyle modifications. A study by Gass (2023) advocated the interconnectedness of physical and mental health and revealed the potential for positive impacts by providing comprehensive care. It is mandated that the changes made to the care plans are based on patient preferences, changing healthcare policies, and growing evidence from various research and studies. This final care coordination plan is based on the preliminary care plan. However, certain modifications have been established based on the recent evidence-based practice guidelines. 

Alignment of Learning Sessions – Best Practices and Healthy People 2030 Objectives

Utilizing evaluative principles from the literature, the learning session content is meticulously compared with established best practices. These best practices include enhancing mental health literacy, establishing community support resources, and introducing mental health education in schools. Moreover, this assessment follows the objectives of Healthy People 2030 related to mental health, which are focused on the prevention, screening, adequate assessment, and effective treatment of mental illnesses (U.S. Department of Health and Human Services, n.d.). The interventions planned in this assessment revolved around these HP2030 objectives. 

Required revisions are based on enhancing efficacy and relevance. For instance, any gaps observed in the instructional content for awareness sessions and school-based curriculum will be revised by incorporating evidence-based research that bolsters understanding and removes stigmatization. Further modifications will be based on Healthy People 2030 objectives, providing a modern-day context that reinforces health promotion at a wider level. These revisions are crucial as they ensure the learning sessions are harmonized with current research, enhance patient engagement, and contribute to the broader national health agenda.


To conclude, the evaluation of preliminary care coordination focuses on developing patient-centered interventions to address mental health issues in the community. These interventions are directed by ethical principles of healthcare practices and policies to improve care quality and accessibility. The communication of such coordinated plans is based on prioritizing patient-centeredness and a holistic care approach to ensure patients are fully engaged, and care plans are tailored according to the concerned individuals’ needs and preferences.

Lastly, it is significant to align the goals of learning sessions with evidence-based practices and Healthy People 2030 objectives to guarantee the currency and relevance of the interventions. Ultimately, the goal is to provide adequate and coordinated care to eradicate mental health concerns from the community.


Ahmed, W., Jagsi, R., Gutheil, T. G., & Katz, M. S. (2020). Public disclosure on social media of identifiable patient information by health professionals: Content analysis of Twitter 

data. Journal of Medical Internet Research22(9), e19746. 

Bolton, R. E., Bokhour, B. G., Hogan, T. P., Luger, T. M., Ruben, M., & Fix, G. M. (2020). Integrating personalized care planning into primary care: A multiple-case study of early adopting patient-centered medical homes. Journal of General Internal Medicine35(2), 428–436. 

CMS. (n.d.). The Mental Health Parity and Addiction Equity Act (MHPAE). 

Cole, D. M., Thomas, D. M., Field, K., Wool, A., Lipiner, T., Massenberg, N., & Guthrie, B. J. (2018). The 21st Century Cures Act implications for the reduction of racial health disparities in the U.S. criminal justice system: A public health approach. Journal of Racial and Ethnic Health Disparities5(4), 885–893. 

Creary, M. S. (2021). Bounded justice and the limits of health equity. Journal of Law, Medicine & Ethics, 49(2), 241–256.

Gass, N. (2023). A need for a holistic approach to mental healthcare. Nature Mental Health1(6), 388–388. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan

Latha, K., Meena, K. S., Pravitha, M. R., Dasgupta, M., & Chaturvedi, S. K. (2020). Effective use of social media platforms for promotion of mental health awareness. Journal of Education and Health Promotion, pp. 9, 124. 

Richter, A., Sjunnestrand, M., Romare Strandh, M., & Hasson, H. (2022). Implementing school-based mental health services: A scoping review of the literature summarizing the factors that affect implementation. International Journal of Environmental Research and Public Health19(6), 3489. 

Siddiqui, S., Morris, A., Ikeda, D. J., Balsari, S., Blanke, L., Pearsall, M., Rodriguez, R., Saxena, S., Miller, B. F., Patel, V., & Naslund, J. A. (2022). Scaling up community-delivered mental health support and care: A landscape analysis. Frontiers in Public Health, p. 10, 992222. 

U.S. Department of Health and Human Services. (n.d.). Mental health and mental disorders—Healthy people 2030 | health. 

World Health Organization. (2022, June 17). Mental health. World Health Organization. 

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